Deep Neck Infection1deep neck space infection

DEEP NECK SPACE INFECTIONS

By Dr. Sandeep

Anatomy of cervical fascia

Cervical fascia

1) Superficial cervical fascia

2) Deep cervical fascia

Superficial Cervical Fascia

• Continuous sheath of fibrofatty subcutaneous tissue• attachments: zygomatic process to thorax and axilla• Contents: platysma & muscle of facial expression• Between superficial and deep layers: fat,sensory

nerves, EJ, AJ, superficial lymphatics

• Marginal mandibular br. of facial n. lies just deep to superficial cervical fascia

Deep Cervical Fascial

1) Superficial layer

2) Middle layer

3) Deep layer

Superficial layer(Enveloping,Investing,Anterior layer)

• Arises from ligamentum nuchae & the spinous process; completely enclose the neck

• Splits at mandible and covers the masseter laterally & the medial surface of medial pterygoid

• encloses trapazius, SCM, omohyoid, parotid and submandibular gland

• Forms floor of submandibular space• Also forms stylomandibular ligament

Middle layer(Cervical layer,Pretracheal layer)

• Encircle strap m. (muscular division)

• Encircle esophagus trachea,thyroid gl., pharynx (visceral division)

• Buccopharyngeal fascia ( part of visceral division that cover constrictor m. and buccinator m.)

Deep layer (prevertebral fascia/carpet fascia)

• Cover vertebral body and paraspinous m.

• Forms floor of the post. Triangle of neck

• Devided into 1. Alar division from base of skull to T2 level 2.Prevertebral division from base of skull to diaphram

Extend laterally as axillary sheath

Carotid sheath• Extend from skull base to

clavicle• Made up of 3 layer of deep

cervical fascia• Contain carotid a., internal

jugular v., vagus n. and sympathetic chain

• Avenues for spread of infection from neck to mediastinum

• Sheath is overlapped by the ant. Border of SCM

Space Involving Entire Length Of Neck

1. Retropharyngeal Space2. Danger Space

(Prevertebral Space)3. Paravertebral Space4. Carotid Sheath Space

Retropharyngeal Space

• Between visceral division of middle layer and alar division of deep layer

• Extend from skull base to T2 level

• Midline raphae divide it into two compartments

• Each lateral space contain retropharyngeal nodes

Danger Space• Between alar division and

prevetebral division of deep layer (locate posterior to retropharyngeal space)

• Extend from skull base to diaphram

• No midline raphae• Infection spread from neck

to posterior mediastinum easily

• Contains loose areolar tissue

Paravertebral Space

• Between prevertebral division of deep layer and vertebral bodies

• Extend from skull base to coccyx

• Infection in this space is rare and spread slowly due to compact connective tissue

Carotid sheath Space

• Made up from all deep cervical fascia

• Infection from any deep fascia can spread to this space (lincoln High way)

• Travels through pharygomaxillary space

Space Limit To Above The Hyoid Bone

1. Parapharyngeal Space2. Submandibular Space3. Masticator Space4. Temporal Space5. Parotid Space

Parapharyngeal Spac Lateral phryngeal Space)(Pharyngomaxillaly Space)

Boundary

• Superiorly : Skull base• Inferiorly : Hyoid bone• Laterally : Medial pterygoid m.• Medially :Buccopharyngeal fascia• Anteriorly : Submandibular space• Posteromedialy : Prevertebral fascia

and retrophryngeal space

Pharyngomaxillary space

• Prestyloid – Muscular compartment– Medial—tonsillar fossa– Lateral—medial pterygoid– Contains fat, connective

tissue, nodes• Poststyloid

– Neurovascular compartment– Carotid sheath– Cranial nerves IX, X, XI, XII– Sympathetic chain

• Stylopharyngeal aponeurosis of Zuckerkandel and Testut– Alar, buccopharyngeal and

stylomuscular fascia.– Prevents infectious spread

from anterior to posterior.

Pharyngomaxillary Space• Communicates

with several deep neck spaces.– Parotid– Masticator– Peritonsillar– Submandibular– Retropharyngeal

Submandibular Space

Divided into 2 spaces by mylohyoid m.

1. Sublingual space (above mylohyoid m.)

2. Submaxillaly space (below mylohyiod m.)

• These 2 spaces can communicate each other by mylohyoid cleft

Masticator Space• Between masticator m.

and superficial layer of deep cervical fascia

(Masticator m. = massestor m.,medial and lateral pterygoid m. and temporalis muscle)

• Locate anterior and lateral to parapharyngeal space

Parotid Space• Between parotid gl. and

superficial layer of deep cervical fascia

• Infection can spread easily to parapharyngeal space due to incompleted encircle at upper

• inner surface of parotid gl.• Contains

– External carotid artery– Posterior facial vein– Facial nerve– Lymph nodes

Space Limit To Below The Hyoid Bone

Anterior Viseral Space (Pretracheal Space)

• Between trachea, esophagus and middle layer of deep cervical fascia

• Extend from hyoid bone to superior mediastinum

• Contains delphin nodes

Etiology• Before the widespread use of antibiotics,

70% of deep neck space infections were caused by spread from tonsillar and pharyngeal infections. Today, tonsillitis remains the most common etiology of deep neck space infections in children, whereas odontogenic origin is the most common etiology in adults.

Causes of deep neck infections include the follwing• Tonsillar and pharyngeal infections• Dental infections or abscesses• Oral surgical procedures • Salivary gland infection or obstruction• Trauma to the oral cavity and pharynx (e.g.,

gun shot wounds, pharynx injury caused by esophageal lacerations from ingestion of fish bones or other sharp objects)

Causes……….• Instrumentation, particularly from

esophagoscopy or bronchoscopy• Foreign body aspiration• Cervical lymphadenitis• Thyroiditis• Mastoiditis with petrous apicitis and Bezold

abscess• Intravenous drug abuse• Necrosis and suppuration of a malignant

cervical lymph node or mass

• As many as 20-50% of deep neck infections have no identifiable source.

• Other important considerations include patients who are immunosuppressed because of human immunodeficiency virus (HIV) infection, chemotherapy, or immunosuppressant drugs for transplantation. These patients may have increased frequency of deep neck infections and atypical organisms, and they may have more frequent complications.

The signs and symptoms of a deep neck abscess develop because of the following

• Mass effect of inflamed tissue or abscess cavity on surrounding structures

• Direct involvement of surrounding structures with the infectious process

• The microbiology of deep neck infections usually reveals mixed aerobic and anaerobic organisms, often with a predominance of oral flora. Both gram-positive and gram-negative organisms may be cultured.

Pathogens• Likely dependent on portal of entry and space involved• Aerobic: Strep-predom viridans and B-hemolytic

streptococci, staph, diphtheroid, Neisseria, Klebsiella, Haemophilus

• Anaerobic: Bacteroides, Peptostreptococcus, Eikenella (often clinda resistant), FUsobacterium, B fragilis

SPECIFIC DEEP NECK INFECTION

PARAPHARYNGEAL SPACE INFECTION

• Most common cause : Peritonsillar infection• Typical finding 1.Trismus 2. Angle mandible

swelling 3. prolapse of tonsil &

tonsillar fossa 4. marked odynophagia

Others : fever, limit neck motion,neurologic deficit (C.N 9,10,12 paralysis)

Parapharyngeal space abscess

Potential complications

• Laryngeal edema

• Spread of infection to retropharyngeal space

• Horner's syndrome

• Cranial nerve palsies

• Suppurative jugular thrombophlebitis (lemierre syndrome)

• Carotid artery erosion

Lemierre’s Syndrome

• Septic thrombophlebitis of internal jugular vein

• Septic emboli – lung / liver abscesses / septic arthritis

• Fusobacterium necrophorum

PARAPHARYNGEAL SPACE INFECTION

Treatment1. Evaluate and maintain airway & fluid hydration2. Parenteral antibiotic high dose 24-48 hrs.3. If not improve, consider surgical drainage

Pharyngomaxillary/Parapharyngeal/

Lateral pharyngeal space• Never approach

intraorally• Traditionally: Mosher

incision• Horizontal neck incision

follow carotid sheath into space finger dissect below submandibular gland, along posterior belly of digastric deep to mastoid tip toward styloid

PARAPHARYNGEAL SPACE INFECTION

Surgical drainage

Peritonsillar Space• Suprahyoid

• Medial—capsule of palatine tonsil

• Lateral—superior pharyngeal constrictor

• Superior—anterior tonsil pillar

• Inferior—posterior tonsil pillar

• Infection leads to quinsy.

• Needle aspiration, I&D, quincy tonsillectomy all equally effective initial management with 10-15% recurrrence rate.

SUBMANDIBULAR SPACE INFECTION

Most common cause : Dental caries

• Anterior teeth & first molar : infection enter sublingual space

• Second & third molar : infection enter

submaxillary space

SUBMANDIBULAR SPACE INFECTION

• Organisms - Mixed of aerobes(alpha hemolytic strep,

staph) and anaerobes make synnergistic effect of endotoxins

- Consider gram – in immunocompromize host

SUBMANDIBULAR SPACE INFECTION

Clinical feature (True Lugwig’s angina)• Start unilateral and progress

bilaterally• Induration of submandibular region

and floor of mouth ( severe cellulitis)• Tongue pushed posteriorly and

superiorly (cause airway obstruction)

• Drolling, odynophagia, trismus, fever

• No purulence(due to no time to developed)

SUBMANDIBULAR SPACE INFECTIONTreatment• Early stage (unilat,mild swelling and edema) -IV antibiotic, extration of

infected tooth • Advance stage (bilateral swelling, dysphagia with

drolling) -early airway intervention -surgical drainage

(submandibular incision)

RETROPHARYNGEAL SPACE INFECTION PREVERTEBRAL SPACE INFECTION

Most commmon cause • In children -retropharyngeal lymphadenitis from

nose,PNS,ET)• In adult -regional truma and endoscopic procedure

RETROPHARYNGEAL SPACE INFECTION PREVERTEBRAL SPACE INFECTION

Clinical feature• In children irritability,neck rigidity,

fever,drolling,muffle cry, airway compromise

• In adult fever, sore throat,

odynophagia, neck tenderness, dysnea

RETROPHARYNGEAL SPACE INFECTION PREVERTEBRAL SPACE INFECTION

Clinical feature • Retropharyngeal space abscess

form abscess lateral to midline• Prevertebral space abscess form abscess in midline• Mediastinitis Dysnea,chest pain, tachycardia,

fever,wideded mediastinum

RETROPHARYNGEAL SPACE INFECTION

PREVERTEBRAL SPACE INFECTION

Investigation1. Lateral neck film - C2 > 7 mm. both

children and adult - C6 > 14 mm. in children > 22 mm. in adult.2. Chest film - detection of mediastinitis

RETROPHARYNGEAL SPACE INFECTION PREVERTEBRAL SPACE INFECTION

Treatment Surgical drainage1. Intraoral drainage -for acute retropharyngeal

abcess in children2. External drainage (Dean) -Lesion beyond pharyngeal

level -Airway compromise -Involve other deep neck

spaces

PARAVERTEBRAL SPACE INFECTION

• Most common cause Penetrating trauma (F.B, endoscope)

TB spine• Infection spread slowly and

more localize due to compact CNT.

Clinical feature -Same as others posterior

space abscess -Vertebral osteomyelitis

and spinal instability

MASTICATOR SPACE INFECTION

• Most common cause Dental carices

Clinical feature• Extream trismus with minimum

facial swelling - Massesteric space (lateral compartment) : edema at ramus of mandible - Ptrygomandibular space (medial

compartment): edema at retromolar trigone

MASTICATOR SPACE INFECTION

Treatment1. Intraoral drainage (medial compartment) - along inner margin of mandibular ramus

to the retromolar trigone 2. External approch (lateral compartment) - submandibular incision - preauricular incision or Gilles incision for

temporal space abscess

PAROTID SPACE INFECTION

• Most common cause : Bacterial retrograde from oral cavity

Clinical feature• high fever, weakness, mark

swelling and tenderness of parotid gland,fluctuation,pus at stensen’s duct

PAROTID SPACE INFECTION

Treatment• IV ATB• Surgical drainage indicated for -fluctuation -medical failure after 24-48 hr. or progression of disease

COMPICATION OF DEEP NECK INFECTION

1. Internal jugular vein thrombosis2. Cavernous sinus thrombosis3. Neurologic deficit4. Osteomyelitis of the mandible5. Osteomyelitis of the spine6. Mediastinitis7. Pulmonary edema8. Pericarditis9. Aspiration10. Sepsis

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